*Kaja Põlluste, assistant professor of health care management1, Georg Männik, member of managing board2, Runo Axelsson, professor of health management3
1 Department of Public Health, University of Tartu, Ravila 19, 50411 Tartu, Estonia, 2 ERGO Insurance Co, Estonia, 3 Nordic School of Public Health, Gothenburg, Sweden
Correspondence to : K Põlluste [email protected]
| Introduction |
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The health of the population has worsened in most countries in central and eastern Europe during the transition period, but little has been written about the reforms in the field of public health during this time, and little evidence has been presented on the links between these reforms and the health of the population.
We describe public health reforms in Estonia, focusing on the institutional structure, the reform rationale, the specific proposals and reform processes, the achievements and limitations, and the wider impact of the reforms.1 To describe trends in the health of the population, we use life expectancy, infant mortality, rate of abortions per 100 live births, morbidity rates (tuberculosis, HIV, sexually transmitted diseases), and the level of individual risk factors (smoking, diet, alcohol consumption). The study is based mainly on an analysis of previously published reports and official statistics.
| Institutional structure |
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After the political changes in the beginning of the 1990s, the importance of a population based approach to public health was recognised in Estonia, and the understanding and application of the concept of health promotion became more comprehensive.2-4
In 1993 the Ministry of Social Affairs was established and included a Department of Public Health, which was seen as a source of modern health promotion in Estonia. Health promotion was introduced in the curriculum of medical and nursing training at the University of Tartu, and public health training for civil servants and teaching staff was started.4 5
| The reform rationale |
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In general, democracy is considered to be good for the health of the population.6 When starting to build up a democratic society in the beginning of the 1990s, Estonia, like most other countries in central and eastern Europe, experienced a rapid worsening in population health indicators. From 1988 to 1994, the life expectancy of males decreased by 5.5 years, due mostly to increased mortality in men of working age. The average life expectancy of men and women showed a big difference.7
In 1994, 56% of the male population died before the age of 65. Most of these deaths were caused by external factors, particularly at younger ages, where injuries, poisonings, homicides, and suicides made up about three quarters of the causes of death.7 Compared with Sweden, for example, the injury death rate for men was about six times higher, and for some types of injuries, such as alcohol intoxication and homicide, death rates were 10 times higher.8
Another serious public health problem since the beginning of the 1990s has been the continual increase in new cases of tuberculosis,7 especially multi-drug resistant tuberculosis. About half of these patients are alcohol misusers, but homeless and poor people are also at great risk.9
Reproductive health and sexual behaviour in the first half of the 1990s was described by high numbers of abortions and a growth of new cases of sexually transmitted diseases.7 The number of smokers and high consumers of alcohol started to increase in 1990.10 The weekly consumption of alcohol in Estonia was significantly higher among both men and women in Estonia than in the other Baltic countries.11
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